Ketelaars et al. International Journal of Emergency Medicine (2018) 11:12 International Journal of https://doi.org/10.1186/s12245-018-0173-z Emergency Medicine ORIGINALRESEARCH Open Access Emergency physician-performed ultrasound-guided nerve blocks in proximal femoral fractures provide safe and effective pain relief: a prospective observational study in The Netherlands Rein Ketelaars1* , Joram T. Stollman2,3,EvelienvanEeten2, Ties Eikendal2,JörgenBruhn1 and Geert-Jan van Geffen1 Abstract Background: The treatment of acute pain in the emergency department is not always optimal. Peripheral nerve blocks using “blind” or nerve stimulator techniques have substantial disadvantages. Ultrasound-guided regional anesthesia may provide quick, safe, and effective pain relief in patients with proximal femoral fractures with severe pain. However, no evidence exists on emergency physician-performed ultrasound-guided regional anesthesia in these patients in Dutch emergency departments. We hypothesized that emergency physicians can be effectively trained to safely perform and implement ultrasound-guided femoral nerve blocks, resulting in effective pain relief in patients with proximal femoral fractures. Methods: In this prospective observational study, emergency physicians were trained by expert anesthesiologists to perform ultrasound-guided femoral nerve blocks during a single-day course. Femoral nerve blocks were performed on patients with proximal femoral fractures. A system of direct supervision by skilled anesthesiologists and residents was put in place. Results: A total of 64 femoral nerve blocks were performed. After 30 min, blocks were effective in 69% of patients, and after 60 min, in 83.3%. The mean reduction in pain scores after 30 and 60 min was 3.84 and 4.77, respectively (both p < 0.001). Patients reported a mean satisfaction of 8.42 (1 to 10 scale). No adverse events occurred. Conclusions: Ultrasound-guided femoral nerve block is an effective, safe, and easy to learn (single-day course) procedure for emergency physicians to implement and perform in the emergency department. Patient satisfaction was high. Background such as opioids and decrease their side-effects [7, 8]. The treatment of acute pain in emergency department Also, undertreated pain and inadequate analgesia have (ED) patients is not always optimal [1, 2]. Fortunately, in the potential to cause delirium in patients with proximal patients with proximal femoral fractures, peripheral femoral fractures [9]. Fascia iliaca compartment blocks nerve blocks are used increasingly to obtain adequate (FICB) have been performed in hip surgery patients and pain relief [3–6]. In addition to providing pain relief, it have shown the potential to reduce the incidence of may decrease the administration of systemic analgesics perioperative delirium in these patients [10]. Nerve blocks in femoral neck fracture patients can be * Correspondence: [email protected]; [email protected] achieved using different techniques. The FICB is a 1 Department of Anesthesiology, Pain and Palliative medicine, Radboud “blind” technique in which surface anatomy landmarks university medical center, Geert Grooteplein-Zuid 10, 6525 GA Nijmegen, The Netherlands are used to determine the needle insertion point, and Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Ketelaars et al. International Journal of Emergency Medicine (2018) 11:12 Page 2 of 7 tactile feedback guides the correct needle position. any sign of infection at the injection site, hemorrhagic Techniques based on surface landmarks have a higher diathesis (e.g., hemophilia and use of anticoagulant drugs incidence of paresthesia during performance of the block with international normalized ratio (INR) > 2.0), an allergy [11]. Furthermore, they produce blocks with a slower onset, to ropivacaine, and multiple traumata. lower quality, and shorter duration compared to an A 1-day course and an e-learning module were devel- ultrasound-guided technique [4, 11, 12]. A nerve oped by a collaboration of anesthesiologists with extensive stimulator-guided femoral nerve block makes use of elec- experience in UGRA and EPs experienced in general trical nerve stimulation to locate the femoral nerve. If a ultrasound. Every EP and EP in training participated in minimal electrical current still elicits quadriceps muscle this hands-on course focusing on UGRA of the femoral contractions, the optimal needle tip position is obtained. nerve and FICB. The online pre-course e-learning module Especially in proximal femoral fracture patients, these con- and course lectures dealt with basic theory of ultrasound, tractions may be painful and are therefore undesirable [4]. pharmacology of local anesthetics, indications, relevant Ultrasound-guided nerve blocks may overcome the anatomy, block techniques, complications and their treat- aforementioned drawbacks. Ultrasonography allows iden- ment, and follow-up. Live anatomy and practical block tification of relevant anatomical structures and continuous techniques were taught on human cadavers at the needle tip visualization, and even the spread of local Radboud Anatomy Department. Scanning techniques and anesthetic (LA) may be observed. Ultrasonography in sonoanatomy were taught and practiced on the partici- regional anesthesia has increased the success rate and pants themselves. Ultrasound-guided needle handling was reduced the complications of peripheral nerve blocks [13]. practiced on blocks of tofu with tiny artifacts inserted. Traditionally, only anesthesiologists performed The UGRA-trained EPs were supervised by skilled ultrasound-guided regional anesthesia (UGRA). In (resident) anesthesiologists for five, or more if desired, recent years, though, emergency physicians (EPs) have ultrasound-guided femoral nerve blocks or FICBs until been adopting this technique [14–16]. However, in The the EPs had gained the knowledge, expertise (as judged Netherlands, a lack of evidence exists on EP-performed by the anesthesiologist), and confidence to perform the UGRA in proximal femoral fracture patients. procedure independently. A dedicated pool of anesthesi- An ultrasound-guided femoral nerve block and FICB ologists and residents with extensive experience in appears to provide quick, safe, and effective acute pain UGRA provided immediate and direct supervision on relief and could therefore be a valuable tool adding to weekdays during regular business hours. Outside of current pain management regimes in Dutch EDs [7, 17]. these hours, supervision was provided depending on the However, EPs should gain relevant knowledge on basic availability of a skilled anesthesiologist or resident. ultrasonography, local anesthetics, nerve block indications, Before the ultrasound-guided femoral nerve block or relevant anatomy, block techniques, and complications. FICB was performed, oral informed consent was obtained Relevant skills to acquire are ultrasound scanning as part of the standard operating procedure (SOP). No techniques, recognizing sonoanatomy, and ultrasound- sedative premedication was administered prior to the guided needle handling. We hypothesize that EPs can be procedure. effectively trained to safely perform ultrasound-guided The ED SOP was jointly written by anesthesiologists femoral nerve blocks, resulting in effective pain relief in and EPs, in accordance with the existing SOP for patients with proximal femoral fractures. ultrasound-guided femoral nerve blocks performed by anesthesiologists in the operating room. It prescribes Methods a sterile procedure and a conservative maximal LA Design dosage to minimize risks of local anesthetic systemic A prospective observational study in ED patients with toxicity (LAST). Vital parameters (continuous electro- proximal femoral fractures was conducted from June 2014 cardiogram, pulse rate, oxygen saturation, respiratory until June 2017. The aim of the study was to evaluate the rate, and blood pressure) are monitored and contin- effectiveness, safety, and satisfaction of EP-performed ued for 30 min after the procedure. The skin is ultrasound-guided nerve blocks in the emergency prepped and draped, and face masks, caps, sterile department. gloves, and a sterile probe cover are donned. Sterile ultrasound transmission gel and a Stimuplex® Ultra Recruitment and setting 22G 0.64 × 50 mm, 30°, short bevel (B. Braun, Mel- Adult patients admitted to the Radboud university medical sungen, Germany) non-traumatic needle are used. center ED with a proximal femoral fracture, including The LA consists of ropivacaine 0.375%, in (four) la- trochanteric and femoral neck fractures, in whom an beled 10-ml syringes, to allow for a high-volume ultrasound-guided femoral nerve block or FICB was block without exceeding the maximum dosage. Alter- planned in the ED were included. Exclusion criteria were natively, ropivacaine 0.75%, which is also used by Ketelaars et al. International Journal of Emergency Medicine (2018) 11:12 Page 3 of 7 anesthesiologists for providing surgical pain relief, can Statistical analysis be used. The maximum allowed dose of LA is Normally distributed